mus t ini t ia te a formal study not only to determine what schedule of on-site at tending coverage is optimal, but also to establish guidelines for the activit ies of at tending physi- cians when they are on duty wi th housestaff. These guide- lines should address the questions of how faculty can best provide quali ty pat ient care, housestaff supervision, and ed- ucat ion in the ED while also considering the resident 's need for graded responsibi l i ty and independent practice.

Robert K Knopp, MD, FACEP Department of Emergency Medicine Valley Medical Center Fresno, California

1. Asch DA, Parker RM: The Libby Zion case. N Engl J Med 1988; 318:771-775.

Academic Productivi ty or Petulant Work Aversion?

In response to the paper by Henneman et a] in this issue of Annals. we wil l t ry to describe our phi losophy on 24- hour a t t end ing coverage. Our pos i t i on has no t changed since our previous art iculation, b3 but we wil l react to the slightly changed focus of the survey presented

The former rat ionale was that noncoverage is good educa- t ion for residents because it enables them to develop inde- pendence. The reason for always choosing the night shift, weekends, and holidays for the development of that inde- pendence was always skirted. Now it may be inferred that the night shift is not only too slow to be a productive cli- mate for resident education, but that because academic at- tending physicians have a responsibi l i ty to produce academ- ically, this night coverage is an unfair burden. It will prevent t hem from doing research, wri t ing papers, and pursuing other academic endeavors that will lead to promotion, and in rum to re tent ion at the part icular ins t i tu t ions that man- date promot ion for cont inued employment .

Addit ional findings in the Henneman paper are that resi- dents would l ike for at tendings to spend less t ime perform- ing pr imary patient care and more t ime in direct supervi- sion and teaching of residents. This survey, based on a combinat ion of resident and at tending opinion from slightly more than half of the total surveyed, seems to indicate that those programs that require 24-hour at tending coverage also require more pr imary pat ient care from the at tending physi- cians. The implied converse however, is yet to be demon- strated, namely that those programs requiring nei ther 24- hour coverage nor pr imary pat ient care from the at tending p h y s i c i a n provide bet ter ins t ruct ion. The study, however, fails to show any stat ist ical difference regarding resident su- pervisor and education. It would also appear that at tendings from programs wi th less than 24-hour coverage are less present in the emergency depar tment during dayt ime hours, al though this difference, apparent in Table 1, is never ana- lyzed and how it might reflect as percentages is not ex- plained.

Moreover, there is an implied at t i tude that it is somehow inferior or undesirable for at tending physicians to provide pnma~y pat ient care. In fact, it can enhance the resident 's experience i f the at tending staff is will ing to care for pa- t ients who have litt le or no teaching value to the resident. One can only presume that this follows the role model pro-

vided by some other specialties wherein at tending physi- cians have an active clinical role (while on service) only a very small port ion of the year except for some minor clinic responsibilit ies. The role model provided by surgical spe- cialties is ignored, as is the historic role of bedside teaching art iculated by Osler. It would have been helpful to define pr imary pat ient care, as this may range from directing a ma- jor t rauma case or performing a procedure {this l imi t ing res- ident experience) to protect ing the residents from cases wi th poor educational value, such as medicat ion refills.

Let us review the purpose of at tending physicians because we th ink that the role is becoming subverted by the unnec- essary focus on resident education.

The pr imary responsibil i ty of an ED, be it academic, pub- lic, or private is to care for the clinical problems that are presented. There is also a frequent responsibi l i ty to the communi ty in regard to supervision of the prehospital care system relating to that communi ty and inst i tut ion. There are a l so d i s a s t e r r e sponse and f r e q u e n t soc ia l respon- s ibi l i t ies as the ED is often the only place that one can enter the medical delivery system, even if the problem is more social than medical. This involves complex transfer relationships, a s well as political, economic, and social con- ceres that extend far beyond the complex medical concerns of the individual patients. To ignore these responsibili t ies or to renounce them to part ial ly trained residents is nei ther wise nor effective. It is enough t o ask the residents to ac- quire the fluency of emergency medicine as a new language. To expect t hem to be responsible for all the senior admin- istrative, political, economic, and social obligations of the depar tment is unfair to the resident and the insti tution.

We believe that the night shift can be viewed as an oppor- tuni ty for the very kind of teaching that both resident and at tending alike state are missing from training programs. And if the workload is so slow that there is noth ing to teach from on the night shift, why have a resident there at all? We have found in our private hospital rotat ions that there is not enough work to support two physic ians 2 4 hours per day in any of the private EDs. We therefore assign the residents only to those shifts that require double cover- age. Curiously, our residents have never s tated that they would prefer to cover the night shift on which the at tending would not have to do so much pr imary pat ient care.

18:1 January 1989 Annals of Emergency Medicine 106/167

EDITORIALS

The academic role of the emergency physician has been studied by Sanders et al. 4 They compared clinical, admin- istrative, and research t ime for emergency medicine, car- diology, and orthopedics. To our surprise, emergency medi- cine had the fewest c l inical hours. Not to our surprise, emergency medicine had the fewest research hours. It ap- pears that the bulk of the academic emergency physician t ime is spent in administrat ion. It is our opinion that this is by choice and represents a mispercept ion of wha t is neces- sary to obtain promot ion , as well as a mispercep t ion of what academics are all about.5, 6

We do not understand where the idea comes from that academic emergency physicians have few clinical respon- sibilities because they train residents. We do not understand where the idea comes from that academic emergency physi- cians do not have to work very hard to succeed. We do not understand where the idea comes from that academic emer- gency phys i c i ans shou ld no t have to work u n p l e a s a n t shifts.h8

The actual i ty is that it requires great mot ivat ion and ded- ication to be an academic emergency physician. There are obligations to clinical, administrat ive, and teaching needs. But if one is to be an effective role model, one cannot shirk any of these areas. This means for a longer average work week than a private practice counterpart, and it also usual ly means a lower salary. To many academic physicians, this is a reason not to work very hard, and to avoid the clinical duties because there is no direct or indirect compensat ion for those hours and because these clinical duties are per- ceived as interfering wi th research and other academic pro- ductivity. But we mus t remember that our specialty arose because of the need to deliver effective clinical care for the variety of problems that present to an ED. 9 We should keep that f i rmly as our standard because wi thout i t there is no need for the specialty of emergency medicine.

Another argument that we find part icularly specious and perhaps illogical is that there is no evidence that at tending supervision makes a difference to pat ient outcome. That ig- nores the large experience of ins t i tu t ions that have had to endure the tragedies caused by the inappropr ia te or mal- adroit decision making of the unsupervised, untrained, and wel l -meaning but errant house officer. To argue tha t one needs a prospective, controlled study of this makes as much sense as to argue that appendectomy is unproven, and that unt i l there is a prospective, controlled s tudy of appendicit is wi th and wi thout appendectomy, it is mere opinion to con- clude that appendectomy is life-saving.

If there is no need for at tending supervision, then why have attendings at all? This in fact was the style of resident training for many years in many specialties. No one who survived the experience can fail to remember cases that had awful and tragic outcomes that could have been prevented by someone wi th experience having been there.

The Henneman article suffers from serious methodologic flaws as well because the amount of t ime spent in various endeavors is all est imated; there is no gradation of either

resident or at tending quality; and there is no es t imate of academic product ivi ty from the programs that require 24- hour at tending coverage versus those that do not. We do not believe that anyone would be able to document, even in numbers alone never mind in quality, that there are more papers, books, research projects, and journals produced by those academic depar tments that provide no or only partial night coverage.

There are many oppor tuni t ies in academic emergency medic ine that wil l produce much fulfillment, but to suc- ceed in being a leader in one's field requires great commit- ment, self-discipline, and many hours of work. There are no shortcuts . We believe tha t the mos t effective depa r tmen t will provide 24-hour at tending presence. If other programs do not, let them deal wi th their own internal adminis trat ive problems, and let the resident applicants make the choice of how they wish to be supervised. In the end, this argu- ment will become academic because third-party payers and state legislatures, as well as others, wil l mandate 24-hour at tending coverage.

To summar ize our position: emergency medicine is not an easy specialty. It requires great energy,, imagination, com- mi tment , and experience. We believe that the best pat ient care, the best adminis trat ive structure, and the best resident education is provided by the 24-hour supervision of high- quali ty and experienced at tending physicians.

Let's stop whining about how hard our lives are in aca- demic medic ine and get on wi th the business of training future leaders in our field.

Peter Rosen, M D Emergency Medical Services Vincent Markovchick, M D Emergency Medicine Residency Program Denver General Hospital Denver, Colorado

Richard Wolfe, M D Depar tment of Emergency Medicine University of Colorado Health Sciences Center Denver

REFERENCES 1. Rosen P, Markovchick VS: Attending coverage. Ann Emerg Med 1985;14:897-899. 2. Rosen P, Markovchick VS: Attending coverage (letter). Ann Emerg Med 1986;15:765. 3. Rosen P, Markovchick VS: Twenty-four hour coverage: Economics, aca- demics, or comforts? [editorial). ] Emerg Med 1985;3:489: 4. Sanders AB, Spaite DB, Smith R, et ah Allocation of time in three aca- demic specialties. J Emerg Med 1988;6:435-537. 5. Rosen P, Harwood-Nuss A: The academics of emergency medicine. J Emerg Med 1988;6:425-426. 6. Krome RL: Up the academic ladder. J Emerg Med 1985;3:59-64. 7. Olson CM: Shift work. I Emerg Med 1984;2:37-45. 8. Rosen P: Night shift and the emergency physician. [ Emerg Med 1984;2:29-31. 9. Rosen P: The biology of emergency medicine. JACEP 1979;8:280-283.

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